
LIBRARY OF CONGRESS, 



Chap.. ... Copyright No. 

ShelfJdfiJL 



UNITED STATES OF AMERICA. 

l^X- '- 



Practical 

Suggestions 

TO THE 

/VWdicgl Fxarr>ii)ers 



NEW-YORK LIFE 



Insurance Company. 




Copyright, 1897, by the New- York Life Insurance Co. 

L. 



SPECIAL NOTICE. 



IF, after any examination, the Medi- 
cal Examiner decides to report ad- 
versely upon tne case, he is requested, 
before he sends his examination to the 
Company or Manager, or delivers it to 
the Agent, to write the Company con- 
fidentially, giving the Name, Date of 
Birth, Occupation and Residence of the 
Applicant, together with the reason for 
his unfavorable opinion ; and blank 
forms are furnished by the Company 
for this purpose. Such confidential let- 
ter must be mailed by the Examiner 
so that it -will reach the Home Office 
before the regular Report itself . 

Again, if for any reason the Medical 
Examiner prefers to do so, he is au- 
thorized and requested to send his Re- 
ports direct to the Home Office. It is 
not necessary that he should report or 
disclose to any one the result of his 
examination. 



Medical Examiners 

OF THE 

NEW=YORK LIFE 

INSURANCE COMPANY. 



THE following remarks and instructions 
are not put forth as completely covering the 
work, and are therefore not to be understood as 
fully prescribing the duties of the Medical Ex- 
aminer. They are intended rather to point out 
the manner in which examinations may be 
readily and effectively made, and to guide those 
among our Examiners who may not yet be al- 
together familiar with making examinations for 
Life Insurance. They should be regarded, in 
a measure, as a confidential communication 
from the Company. 



In return, our Examiners are requested to 
communicate directly and confidentially with 
the Medical Department at the Home Office 
of the Company at any time and in all cases 
when, in their opinion, it is desirable or neces- 
sary. 

Any information from them in regard to the 
Climate, Epidemics, Hygiene, or diseases pe- 
culiar to the localities in which they reside, will 
be welcome and highly appreciated. 



LIFE INSURANCE.-THE APPLICANT. 

The business of Life Insurance is based on 
the fact that, while the longevity of a single 
individual is uncertain, there is a fixed law, 
determining, within narrow limits, the aver- 
age age at death of large numbers of indi- 
viduals of the same age; and that, under this 
law, it may be expected that any man in 
sound health, of temperate habits, with a good 
family history, and a healthful occupation, will 
live as long as the average of those of the 
same age, i. e., will live out his " Expectation 
of Life." 



Involving, as it does, the purely medical ques- 
tions cf the past and present health, the family 
history, the habits, hygienic surroundings and 
occupation of the individual, the business of Life 
Insurance requires for its successful prosecution 
the assistance of those whose lives are spent in 
the study of such questions — Medical Practi- 
tioners; and because of the large sums of 
money involved, and the dangers of fraud, it is 
necessary that the Medical Examiners of a Life 
Insurance company should possess, besides a 
good medical knowledge, upright character and 
sound judgment. 

The chief essential to the success of a Life 
Insurance company is the maintenance of a 
high standard in the selection of its risks. These 
should always be fully up to the average in 
health, of temperate habits, of good personal 
and family history, and of healthful occupation; 
and they should approximate closely to the 
average physical conformation of healthy men. 
Of the health, habits, history and occupation of 
an Applicant for insurance, physicians are able 
to fully inform themselves; but the questions of 
average physical conformation or " build," and 
the average probable longevity of an indi- 



5 



vidual, so rarely present themselves for their 
consideration that the table of height and weight 
on page 22 will be found convenient for refer- 
ence. 



MEDICAL EXAMINERS. 

Medical Examiners are selected solely for 
their moral and professional standing in the 
communities in which they reside. They hold 
their appointments direct from the Company, 
and retain their positions as long as their ser- 
vices prove satisfactory to it. 

They are the trusted advisers of the Com- 
pany, and their relations with the Medical De- 
partment are personal and confidential. It is 
their duty to examine Applicants for insurance 
presented to them by the Agents of the Com- 
pany, to furnish, on blanks provided for that 
purpose, full and complete reports of the 
family and personal histories, of the physical 
condition of the Applicants, and to give their 
opinion as to the value of the risks. For 
such examinations they receive the fixed 
fee of the Company, and this fee is paid 



whether the Applicant is approved or disap- 
proved by the Examiner. The fees are paid 
by the Company and not by the Applicants or 
Agents; and Examiners are not dependent, 
for their appointment, dismissal, or fees, upon 
either Applicants or Agents. 

It is to the interest of all concerned that 
the relations of the Examiner with both Ap- 
plicants and Agents should be cordial and 
friendly. To the Applicants his position should 
be of the same delicate and confidential nature 
as thai, shown to patients who entrust them- 
selves to his professional care; and, while it 
is often the duty of the Medical Examiner to 
oppose his judgment to the wishes of Agents 
and decline to recommend some of the Appli- 
cants, yet the Medical Examiner, by the exer- 
cise of tact and judgment, and especially by 
firmness in his convictions, should be able to 
avoid serious friction, and thereby secure that 
harmony so essential to a pleasant intercourse 
and to satisfactory business results. 

He should always bear in mind that the 
Agent's livelihood depends on his ability to 
obtain Applicants, and he naturally depends 
on the Medical Examiners of the Company 



which he represents for reasonable co-operation, 
that be may secure the fruit of his labor. 

To the Agents belongs the task of se- 
curing Applicants for Insurance, and to the 
Medical Examiners that of selecting from such 
Applicants only those risks which may be 
safely accepted by the Company. 

In ordinary medical practice the patient en- 
deavors to describe fully and clearly every 
detail of the disease of which he complains, 
so as to give the physician a complete un- 
derstanding of his condition. He conceals 
nothing from him, and the physician has only 
to consider the evidence before him and, re- 
jecting that which is worthless, to act upon 
that which is of value. 

In examinations for Life Insurance, on the 
contrary, the Applicant wishes to appear well 
and strong. He declares that he is in sound 
health, and in all his statements as to his per- 
sonal and family history he is inclined to em- 
phasize only those features which appear to 
him favorable to his case, and, if dishonest, 
the Applicant tries to mislead the Examiner, 
and so distorts the facts that it becomes very 
difficult to draw a correct conclusion. In short, 



a Patie?it assists his physician ; an Applicant 
for Insurance frequently antagonizes the Medi- 
cal Examiner. 

Therefore, besides the skill of the ordinary 
practitioner, the Examiner for Life Insurance 
must bring to his task complete independence 
of character, absolute integrity, and the ability 
to detect attempts at fraud on the part of 
Applicants or others interested. He must con- 
stantly bear in mind that he is the Guardian 
of the interests of the Company, and that upon 
his vigilance, judgment and integrity depends, 
largely, its success or failure. 



MEDICAL EXAMINATIONS. 

The Medical Examination of an Applicant 
for Life Insurance has for its object to secure 
such information in regard to the family history 
and the past and present health of the Applicant 
as will enable the Medical Board at the Home 
Office, assisted by the opinion of the Medical 
Examiner, to judge whether the Company may 
safely grant the Insurance applied for. 



This object is best secured by following a 
general routine, to be varied as the experience 
of the Examiner or the special circumstances in 
any individual case may indicate. We there- 
fore call your attention to the subjoined 

RULES AND INSTRUCTIONS FOR THE GUID- 
ANCE OF MEDICAL EXAMINERS. 

Familiarization. First of all, you are re- 
quested to thoroughly familiarize yourself with 
the queries on the two sides of the examination 
sheet under the captions. "Answers Made to 
the Medical Examiner.' 7 and " Medical 
Examiner's Report." 

By doing this, you will accomplish two very 
desirable ends : first, you will secure as thor- 
ough an examination and complete information 
as possible : and second, you will avoid much 
correspondence and delay. 

Doubtful Risks. Instances will occasionally 
occur in which you may be in doubt whether 
you ought to examine an Applicant. You 
should not examine any person whose applica- 
tion for insurance has ever been suspended or 
declined by this Company, or within the year 



previous by any other company, without first 
receiving permission from the Home Office for 
such examination ; nor should you examine a 
person whom you positively know to be unin- 
surable. When, in any case, you decline to 
make an examination, you should send a con- 
fidential notice of your action to the Home 
Office on one of the blank forms furnished. 
(See that you have always several of these 
forms on hand.) 

Pensions. Whenever you examine a person 
who is a pensioner, your examination should 
be made with special care, and the grounds on 
which the pension has been obtained should 
be clearly stated. 

Promptness in keeping appointments and 
in making examinations must be strictly ob- 
served, as any delay may cause a loss to 
the Company, to the Agent or the Applicant, 
for which the Medical Examiner is held re- 
sponsible. Competition in this business is so 
acute, that, while we wish the examinations to 
be made at the Examiner's office whenever 
possible, we cannot insist upon having Appli- 
cants call at your office for examination, and 
are therefore obliged to ask you to make ex- 



aminations at any proper place within reason- 
able distance, and at any reasonable hour. 

Privacy. We must also insist that examina- 
tions be made strictly in private, the agent or 
any third person not being permitted to be 
present. 

Self-written. Both the Answers of the Ap- 
plicant and your Report must be made out 
entirely in your own handwriting: and where 
corrections are made, you should indicate that 
they are made by yourself, by adding your 
initials : but you are not to fill in any part of 
the application blank itself. 

Relationship and Pecuniary Interest. If you 
are related to either Applicant or Agent, or if 
you have a pecuniar}- interest in the proposed 
insurance, you must refuse to make the exam- 
ination, and should refer the Agent to some 
neighboring Examiner. 

ANSWERS MADE TO THE MEDICAL 
EXAMINER. 

When an Applicant presents himself for ex- 
amination or is brought by an Agent, the Ex- 
aminer having retired with the Applicant to his 
private office or room provided for the pur- 



pose, should begin the examination by review- 
ing in detail the statements made in the appli- 
cation as to the full Name, the Date of Birth, 
Occupation, etc., of the Applicant, and satisfy 
himself as to the identity of the Applicant, 
and that the application is correctly filled out 
and properly signed. 

The rule of the Company requires that appli- 
cations be filled up and placed in the Examiner's 
hands before examination, and the Examiner 
should consent to exceptions only in those 
cases where some urgent reason is apparent. 

Occupation. This question should develop 
fully whether the applicant is engaged, or is 
likely to engage, in an occupation involving 
any unusual hazard, such as employment on or 
about railroad trains ; use of explosives ; occu- 
pations involving cramped or unhealthy po- 
sitions ; confinement to close, ill-ventilated 
rooms ; exposure to great or sudden variations 
of temperature, etc. 

Under the head of Occupation also, a further 
question is intended to bring out whether the 
Applicant is, or has been, or is likely to be, en- 
gaged in the manufacture, sale or personal 
handling of alcoholic liquors. 



Residence. The object of this query in 
bringing out the liability to Epidemics, to Ma- 
larial influences or any unhealthy environment, 
is evident. 

Habits. The questions relating to the use 
of alcoholic drinks should be asked with a view- 
to determine whether at any time present or 
past, their use is or has been, excessive or 
harmful. 

The Examiner should also be particular to 
ask, in suspicious cases, if the Applicant has 
ever resorted to the so-called " Keeley " or " Gold 
Cure " or other special treatment. If he has, 
give dates, and whether any alcoholics have 
been used since. 

Inquiry must also be made as to the use of 
drugs (Opium, Morphine, Cocaine, etc.). This 
question of Habits is of so great importance, 
that the Company is obliged to take the posi- 
tion that an Examiner fails to do his full duty 
who does not place it in possession of all the 
unfavorable information which he has, or which 
may be reasonably accessible to him. 

If perso?ially acquainted with the Applicant, 
the Examiner should be able to give all the 
facts ; if not acquainted, and there is suspicion 



in his mind, the Examiner should not rest on 
the Applicant's statements, but should secure 
further information, which may be sent to the 
Home Office under confidential cover, if neces- 
sary. 

Blood Spitting. No medical question in the 
entire range of our business requires the exer- 
cise on the part of the Examiner of greater 
care in securing a detailed answer, and no 
question is more frequently answered imper- 
fectly. It is only after a careful study of the 
fullest details that the Company is able to dis- 
tinguish with any degree of accuracy, between 
attacks which should exclude from the benefits 
of insurance, and those which may be safely 
disregarded. The Examiner should therefore 
carefully distinguish between a true Haem- 
optysis and the blood-stained sputum of Pneu- 
monia, or severe Bronchitis. The cause, the 
number of attacks and the extent of each 
Hemorrhage should be carefully inquired into 
and stated. 

Female Risks. Women have usually been 
considered less desirable risks than men, prob- 
ably because they have, in the majority of cases, 
been less carefully examined, owing to the deli- 



i5 



cacy and difficulties which are usually met in 
such examinations; the Examiner should use 
the same care in examining women that he 
does in examining men. Pregnant women, 
under the rule of the Company, are not ac- 
cepted. 

Whenever a female Applicant is to be 
examined, it is advisable to notify the Ap- 
plicant in advance to prepare herself for the 
examination; she should wear a loose, non- 
rustling waist, and no corsets. It would 
be well also if she could be informed that a 
specimen of urine will be required, and let 
her provide herself with a thoroughly clean, 
three-ounce bottle filled with freshly -voided 
urine which may be given to the Examin- 
er, as to the origin of which he should be 
most careful. This precaution will be found 
wise, because in most places where female 
examinations are conducted facilities for ob- 
taining freshly-voided specimens are not ac- 
cessible.. 

The special questions in the examination 
regarding women should be carefully answered, 
and any other information which the Examiner 
may deem pertinent should be given. 



Previous Applications and Examinations. 

The Company especially wishes to know 
whether the Applicant has at any previous 
time been examined for insurance, and failed 
to obtain a policy as applied for. If so, the 
details of when, and by what Company or 
Society, should be fully stated. 

Personal Record. The Medical Examiner 
should secure a complete statement of each 
of the important diseases from which the Ap- 
plicant has suffered; not only with a view to 
determine w T hat effect such disease has already 
produced upon the constitution of the Appli- 
cant, but also as to its liability to recur. 

Write clearly the name of each disease, the 
number of attacks, the date and duration of each, 
its severity, and results, if any. 

All answers should be complete, but as con- 
cise as possible. The aim should be to give 
the facts, but avoid trivial details. Certain 
diseases very important from a Life Insurance 
standpoint often fail for some reason to receive 
satisfactory description. They are as follows : 

Asthma. State cause (if possible), when 
first attacked, the frequency and severity of 
the seizures, and its last occurrence. The Ex- 



armner should distinguish between true Asthma 
and Hay Fever. The frequency with which 
Asthma occurs as a symptom of other diseases 
should also be kept in mind. 

Spitting of Blood. This has already been 
referred to. i,Page I 5-) 

Dyspepsia seems to be often misunderstood 
and imperfectly described. We do not wish to 
know if an Applicant has suffered from an in- 
digestion due to overeating at some time or 
other, but we do wish to know if he has suffered 
from any 77iarked functional disorder, or from 
organic disease of the digestive organs. 

Rheumatism and Gout. Be particular to give 
the number of attacks and the d :h : in- 

dicate whether each attack was severe or not. or 
accompanied b) r any serious complication. It 
is necessary also to distinguish between Articular 
and the so-called Muscular Rheumatism. 

Syphilis. Give the date and character of 
the primary lesion; the character and dura- 
tion of- the secondary or tertiary lesions ; the 
treatment employed, and when it was finally 
discontinued. Never refer to Chancroid as 
Syphilis. Have in mind that one is simply a 
local and the other a constitutional disease. 



Medical Treatment. Ascertain from the Ap- 
plicant whether he has found it necessary to 
consult a physician for any ailment, and if so, 
give the name and address of physician, the 
nature of the ailment, and the date of treatment. 

Family Record. These questions are to de- 
termine what hereditary influences, if any, may 
be expected to shorten the longevity of the 
Applicant. Do not rest content with, nor 
write down any obscure answers. If the Ap- 
plicant describes the health of living rela- 
tives as " fair," or " poor," ascertain in what 
respects they are not in good health, and frame 
the answer accordingly. Where the cause of 
death is said by the Applicant to have been 
due to " change 'of life," or " childbirth," or 
" exposure," or where any such indefinite term 
is used, let the Examiner satisfy hiniself as to 
the exact facts, and record them as concisely and 
correctly as possible in order to eliminate the 
possibility of the impairment being Tubercular. 

In all cases where the final illness of any 
member of the family has been a protracted 
one, it is important to determine whether death 
was due to a disease which may be considered 
in any sense hereditary. 



Declaration and Signature. This completes 
the "Answers Made to the Medical Examiner," 
and is immediately followed by the Declaration 
and Signature of the Applicant, which is to be 
witnessed by the Medical Examiner. 

The Signature of the applicant is an impor- 
tant point, and should be carefully observed. 
Let the Examiner notice the characteristics of 
the signature as well as the Applicant's manner 
in making it. If it is tremulous or shaky, or in 
any way suggestive of nervous affection or a 
possible incipient paralysis, the Examiner 
should search carefully for the cause, and 
record it in his special remarks. He should, of 
course, be careful to distinguish between the 
irregular, jerky signature of one who is unac- 
customed to the pen, and the uniformly tremu- 
lous signature of one who has some central or 
grave nervous lesion. 

Special Notes. Carefully follow any special 
notes of instruction which may appear on the 
examination forms. 

MEDICAL EXAMINER'S REPORT. 

Pulse. This question has been placed first 
in the " Report " in order that the rate and 



character of the pulse may be observed Avhile 
the Applicant is still seated, and before the 
medical examination is begun, and it has been 
disturbed by the incidents of the physical ex- 
amination. 

Measurements. The height, and the dimen- 
sions of the chest and abdomen should be care- 
fully measured, and not estimated. The weight 
should be taken without coat or vest, and where 
for any reason it is necessary to estimate, the 
word " estimated " should be inserted along 
with the figures ; otherwise the Company as- 
sumes the weight to be exact. 

Gain or Loss of Weight. If the Applicant 
has recently gained or lost in weight, the par- 
ticulars should be carefully given. 

If unusual stature or weight is a marked 
characteristic of the Applicant's family, it should 
also be noted. 

In order to show the proper relation of 
height to weight, the following table is pre- 
sented; and where an Applicant is markedly 
over or under weight according to the table 
(say 20% in either direction), the heights and 
weights of other members of the family should 
be briefly noted in the space allotted for ad- 



ditional remarks. This should be carefully | 


done, as its 


bearing on the value 


of certain 


risks 


is izzz :r:ir: : 




TABLES 


OF HEIGHT AND WEIGHT. 


A v e r are : " 


::•-::-. = : 3\.;:Al —Acre 


6 5 - z AO 






--^ >.i^>c 




5 feet 


:~z'zt 


ir. r.-=:z~~-~- ?"- " -A :::': 


123 r:unds. 


s ■• 


1 " 


" 


127 


5 ■« 


2 • 


» 


131 


•5 •• 


3 ■ 


" 


135 


5 •• 


4 


" 


" 


5 ■ 


5 " 


" 


143 


5 ■■ 


6 " 


" 


148 


5 " 


7 


» 


152 


5 " 


1 


« 


157 


5 " 


9 " 


" 


161 


5 •• 


LI 


» 


1G6 


5 •• 


U 


" 


171 


6 •■ 





" 


176 


6 - 


1 




182 


6 •• 


2 




187 


6 - 


S " 


.. .. .. 


192 



i - - ..... 


A WOMAN 


; 4 feet 9 inches in height should weigh 108 pounds. 


I 4 " 10 


" 




111 


4 " 11 


« 




115 


5 " 


" 




118 


5 " 1 


« 




121 


5 " 2 


" 




125 


| 5 " 3 


" 




129 


! 5 << 4 ' 


" 




133 


5 " 5 


" 




137 


i 5 " 6 


" 




141 


J 5 « 7 ■ 


" 




145 


5 " 8 


" 




150 


5 " 9 


" 




154 


5 " 10 


" 




159 


Note. — At younger ages than those given in the table the weights 
rule lighter, and at older ages somewhat heavier ; but for practical 
purposes a variation in either direction of 20 per cent, from the table 
may, other features being favorable, be regarded as entirely com- 
patible with an average expectancy of life. 


We append also a table showing 


THE EXPECTATION OF LIFE. 


A PERSON 


20 yea 

25 


-s old ma 


y be expected to live 42 years or until 62 years old. 

" 39 " " 64 


30 


■ 


„ 35 " " 65 


35 


< 


" 32 ^ « 6 7 t* 


40 


< 


« 28 " " 68 


45 


« 


" 24 " " 69 


50 


* 


" 21 " " 71 


55 


< 


" 17 " " 72 


60 " 


" 14 " <f 74 



23 



Personal Acquaintance. The Medical Ex- 
aminer should state, in its proper place, whether 
he is personally acquainted with the Applicant 
and how long. Note the apparent age c f 
Applicant, and if he appears older than the 
age given by him, attention should be called to 
it and the apparent age given. 

Characteristics. The distinguishing charac- 
teristics, such as Complexion, Color of Hair, 
Color of Eyes, etc., should be correctly stated; 
and in order to do this, the Examiner should 
observe the Applicant in a good light, and all 
examinations should by made in well-lighted 
rooms if possible. Observe the hue of the skin, 
etc., whether healthy or unhealthy. 

Deformity or Maiming. Describe in detail 
aDv Deformity or Maiming, especially where 
locomotion is interfered with ; where a crutch, 
cane or artificial limb is used, the fact should 
be stated, as well as how far it overcomes 
the defect. A risk otherwise good is often 
considerably impaired by an increased liability 
to accident. 

Race. Be particular to answer correctly 
whether the Applicant is a Caucasian (white 
race), or whether he belongs to some other 



race, or is of mixed blood. If mixed, state what 
races. 

Identification. Any striking or distinguish- 
ing mark by which the Applicant may be read- 
ily identified should be noted. This is an im- 
portant point, and should not be overlooked. 
Some physical peculiarity or scar or mark may 
be observed, or something in the shape of the 
teeth, nose deviating to one side, etc., may be 
noted. Be also careful to state whether the 
Applicant bears marks of successful vaccination, 
or small-pox. 

Evidence of Disease. The questions should 
be so directed as to prompt the Applicant's 
memory, and elicit the history of any previous 
ailment; and the physical examination should 
be thorough so as to detect any symptoms of 
past or present disease, not only of the organs 
specifically mentioned, but of any part of the 
body, internal or external. 

Brain or Nervous System. Be on the alert 
to detect any evidence indicative of past or 
present central lesion or grave disturbance. 
Any striking mental peculiarity or mannerism 
should be noted. 

Heart. Note whether the sounds and rhythm 



25 



are normal ; if intermittent or irregular, you 
should, if possible, explain the cause. 

Whenever a murmur is present, state, ist, the 
area of its distribution; 2d, the point of its 
greatest intensity ; 3d, the relation of the mur- 
mur in point of time to the heart sounds : 4th, 
the location of the apex beat, and whether any 
hypertrophy or dilitation be present ; 5th, the 
action of the heart under rigorous exercise ; 
6th, whether the murmur is deemed organic or 
functional. 

Lungs. It is needless to remark that they 
should be examined very carefully, and espe- 
cially when the family or personal history or 
physical conformation suggest a tendency to 
tubercular diseases. 

Stomach and Abdominal Organs. Search 
should be made for any tumor or abnormality, 
for history of colics, or any suspicious symp- 
toms in the neighborhood of the Appendix. 
Examine carefully for Hernia, ascertain whether 
reducible or irreducible, and whether a suitable 
truss is worn. 

Rheumatism and Gout. These have already- 
been referred to. (Page 18.) 

Skin, Middle Ear, Eyes. Any serious or 



suspicions skin affection should be noted and 
described. Blindness and Deafness impair a 
risk, and the Examiner should state the cause 
and extent of either, whether total or partial. 
In case of Middle Ear disease, give details 
and frequency of the attacks, their severity, 
the character of discharge and when last seen. 
General Questioning should elicit the history 
of any disease or ailment not otherwise men- 
tioned. 

Genito Urinary Organs. Be sure that the 
urine examined is that of the Applicant, and 
it should, if possible, be voided in the presence 
of the Examiner. Under no circumstances 
should a Report be based upon a specimen the 
origin of which is in doubt. 

If the urine contains either Albumen or 
Sugar, give, if possible, a brief explanation of 
its probable cause; in the case of sugar, in- 
quire carefully whether its presence has been 
previously detected, and whether any of the 
general symptoms of Diabetes are, or have 
ever been, present. Where the presence of 
sugar in an otherwise apparently perfectly 
healthy person is believed to be due to some 
accidental or passing cause, a second speci- 



men should be examined the next day ; a bet- 
ter opinion of the probabilities can then be 
given. 

Microscopic Examination (unless called for 
by Home Office) is not required ; but if an Ex- 
aminer, for his own satisfaction, makes such 
examination, his Report is always welcome. 

Stricture. If history or symptoms point to 
Stricture, investigation should be made, and 
the actual conditions as to location, probable 
cause, duration and calibre given. 

It should also be stated whether there has 
been treatment, its nature and when. 

Suspicions as to Habits. If the appearance 
of the Applicant, or anything in the course of 
the examination, leads to suspicion of former 
or present intemperate use of alcohol or drugs, 
be sure to state it. 

Review. It is often a matter of surprise to 
us that some of our very best Examiners sub- 
mit to the Company Reports in which there 
are glaring omissions and obscurities, causing 
oftentimes much correspondence and delay. 

We therefore urge our Medical Examiners 
to make it a uniform practice to Review all 
their work, and not make final answers until 



28 



they have done so. If the questions already 
asked do not satisfy them that Applicants have 
given full and true information in all respects, 
they should continue questioning until satisfied 
they have obtained all information which the 
Applicants are able to give. 

Final opinion and advice must be based, not 
only upon knowledge of the actual present 
physical condition of the Applicant as deter- 
mined by the examination, but also upon his 
Habits, Surroundings, and Personal and Family 
History. 

The Company should have the benefit of 
the Examiner's entire knowledge affecting the 
risk ; but where the physical condition of the 
Applicant is thoroughly satisfactory, and the 
value of the life for insurance is, in the Ex- 
aminer's opinion, lessened by other factors, he 
should recomiiiend the risk, calling attention to 
the points to which he thinks exception may 
properly be taken. (See also page 32, under 
" Recommendations.") 

Place of Examination (in the Certificate at 
the bottom of the " Medical Examiner's Re- 
port"). The place should be described as fol- 
lows : "at my office"; "at his residence"; 



29 



" at his omce *' ; "at his farm 3 miles south of 
. . . . " ; " at his country seat 4 miles west 
of . . . " ; and so on. 

Finally, the Medical Examiner should fill in 
the blanks in his Certificate of Examination 
and sign the examination. This completes the 
■• Medical Examiner's Reoort." 



FIELD OF OPERATION. 

The Medical Examiner is expected to act 
only in the community where he resides, and 
should not make examinations in the territory 
of another Examiner except when the latter 
is for any reason not available. In such event, 
he should add to his Report a statement of the 
circumstances which seemed to him to warrant 
his irregular action. 

Appointment. It is not the custom of this 
Company to send a formal commission of ap- 
pointment to its Examiners, and it reserves to 
itself the right to make such changes from 
time to time in its staff of Examiners as seems 
for the best interests of the Company. We 
make this statement because we are often asked 
for letters of commission by Examiners who do 
not know this fact. 



FEES FOR MEDICAL EXAMINATIONS. 

Immediately upon their appointment, all 
Medical Examiners are notified by the Com- 
pany of the fees which are allowed, and these 
fees (whether the Applicant is accepted or re- 
jected by the Examiner) will be paid by the 
Company for each completed examination 
where an Applicant applies for new insurance 
or for an i?icrease of insurance after one trans- 
action has been closed and the policy delivered. 

A double fee is also allowed whenever a 
microscopic examination of the urine is re- 
quested by the Company. 

Only those examinations are regarded as 
complete in which the Medical Examiner has 
secured for the Company all the information 
necessary to enable the Company to decide 
whether the risk is, or is not, acceptable. Com- 
pleteness must also include the ordinary Cer- 
tificate of Health for the delivery of the policy 
at any time within three months of the date of 
the original examination. (The number of cases 
requiring such Certificate will be very small.) 

Fees for medical examinations for the re- 
instatement of lapsed policies or for paid-up 



values must be paid by the Applicant, and are 
not chargeable to the Company. 

The Company will allow only the regular 
schedule fee for each examination, and will not 
be responsible for any charge for mileage or 
other extra service. 

Bills. Medical Examiners are requested to 
send their bills monthly direct to the Home 
Office. Blank forms are provided by the Com- 
pany for this purpose, and will be supplied on 
request. 

Necessity for Complete Papers at Home 
Office. To enable the Company to properly 
check and audit Examiners' accounts, the com- 
pleted application and medical examination 
papers are required at the Home Office. 

Medical Examiners should see that, as far as 
it depends upon themselves, no application or 
medical examination papers are suppressed or 
destroyed; but that, in every instance in which 
an examination has been made, all papers are 
forwarded to the Home Office. 

RECOMMENDATIONS. 

Sometimes the Examiner hesitates to recom- 
mend a risk because of a bad family history or 



of objectionable features in the past history of 
the Applicant, notwithstanding the fact that 
he finds the Applicant personally in excellent 
health at the time of the examination. Accord- 
ing to the experience of the Company, such 
risks may frequently be safely assumed on some 
form of policy. The Examiner must remember 
that the final acceptance or rejection belongs to 
the Home Office, and that his recommendation 
should be such as to give the Company an op- 
portunity to exercise its judgment on the case. 

If, therefore, he finds an Applicant on ex- 
amination, to be in good health and promising 
a good expectancy, he should recommend such 
Applicant, calling attention, however, to what 
he deems the weakness in the case. He should 
say, for instance, in reply to the question 
whether he advises a policy be issued, " Yes, 
subject to family history," or "subject to per- 
sonal history of Rheumatism," or " Colic," or 
" Blood-spitting," or " Physicial Injury," and 
so on. 

Applicants ill with any acute or serious 
chronic disease, should not be recommended; 
or, if the chronic disease is, in his (the Ex- 
aminer's) opinion, entirely compatible with a 



33 



good expectancy of life, he should recommend 
guardedly, subject to the Company's judgment 
as to form of policy, and he should be sure to 
give all the facts. 

Final Decision. Before making final decis- 
ion it is well for the Examiner to ask himself 
whether he would, as a private individual, take 
precisely such risk upon his own account and 
insure the life of the Applicant ; and whether 
he would advise the Company to place hun- 
dreds of similar risks upon its books ? 

Supplementary Report. Whenever the Ex- 
aminer thinks it necessary or desirable (on ac- 
count of his own personal or business relations 
with the Applicant or Agent) to omit a full ex- 
pression (in the examination papers) of his opin- 
ion of the risk, he may forward all papers direct 
to the Home Office ; or, allowing the papers to 
go through the Agent's or Manager's hands, 
may send to the Company a Supplementary 
Report mailed to the Home Office. Such Re- 
port, however, to be of value, must reach the 
Home Office before, certainly not later than, 
the application itself. * 

* Note. — See also "Special Notice" on 2d page. 
34 



EXAMINATION OF URINE. 

For the convenience of the Medical Ex- 
aminers of the Company, we add the following 
in regard to the examination of urine : 

As quickly as possible after it is passed, the 
specimen of urine should be examined with 
respect to each of the following points : 

1. Quantity in 24 hours. 4. Reaction. 

2. Color. 5. Transparency. 

3. Specific Gravity. 6. Albumen or Sugar. 

1. The Quantity of urine passed by an adult 
in good health is about 45 to 50 ounces in 
24 hours ; but it is subject to variations 
within considerable limits, depending upon 
such conditions as the temperature and hu- 
midity of the atmosphere, the activity of the 
skin, the amount of the expiratory exhalations, 
and the amount of fluids or of liquid foods 
ingested. 

In Disease it varies from the enormous 
quantities passed in diabetes, in hysterical 
polyuria and in the amyloid and the old gran- 
ular kidney, to the scanty flow of the febrile 
state and of some forms of disease of the 
kidneys. 

2. The Color is usually a pale yellow or am- 



35 



ber, though it varies with the quantity of urine 
voided. With a copious flow the color is very- 
pale ; with a scanty flow it may be very dark. 

In Disease it varies from the dark, smoky- 
brown of acute Bright's disease, through the 
high-colored urine of the febrile state, and the 
pale straw color of diabetic urine, to the almost 
colorless urine of the hysterical state, and of 
some cases of contracted kidney. 

3. The Specific Gravity of urine may be 
stated at 1,020, under ordinary circumstances, 
although it may vary in health between 1,010 
and 1,025, dependent upon the same causes as 
those which influence the variation in quantity 
and in color. Since the amount of solids ex- 
creted by the kidneys is fairly constant, this 
variation in specific gravity is approximately 
in inverse ratio to the amount of urine voided. 

The Specific Gravity is best obtained by 
means of the Urinometer. This instrument 
is usually graduated between 1,000 (the specific 
gravity of distilled water) and 1,060, and, 
when used, care should be taken that it is per- 
fectly clean and that it does not cling to the 
side of the vessel in which the test is made. 

In Disease this range is increased. In dia- 



36 



betes it may be 1,040, 1,050 or higher. In the 
earlier days of acute Bright's disease, and in 
the febrile state, it is high, and from that it 
ranges to that of the cirrhotic and the amyloid 
kidney, of diabetes insipidus or of the hysteri- 
cal state, where the specific gravity may be 
1,005 or less. Since, however, urine with 
specific gravity 1,010 has been found to con- 
tain sugar, and since the normal specific grav- 
ity has often been noticed in old cases of 
Bright's disease and in severe diabetes, the 
specific gravity cannot be relied on as an ac- 
curate guide to disease. But an average daily 
specific gravity of 1,025 or over is always sug- 
gestive of the presence of sugar, and of 1,015 
or under, of chronic Bright's disease. 

4. The Reaction of normal urine is usually 
acid — due, probably, to acid phosphate of 
soda — but it may be neutral or alkaline. 

The reaction is determined by the use of 
litmus papers. The red becomes blue in the 
presence of an alkaline urine, and the blue 
paper becomes red if the urine is acid. When 
the reaction is not well marked, both the red 
and blue papers should be used. The acidity 
of urine is increased by an albuminous diet, 



37 



and vegetable foods decrease it or render the 
urine alkaline. 

In Disease the acidity is decreased in Anae- 
mia and in some nervous affections, and is 
increased in diabetes and fevers. 

5. Transparency. The urine is naturally 
transparent, but, within the limits of health, 
it may be more or less opaque, on account of 
the presence of 

A. Earthy Phosphates, C. Mucus, 

B. Mixed Urates, D. Bacteria. 

a. The Earthy Phosphates may cause 
normal urine, at the moment it is voided, to 
be opaque. Shortly afterwards they subside and 
form a bulky, flocculent sediment, with clear 
urine above. They may be recognized by the 
fact that the application of heat will increase 
the opacity, while a few drops of Nitric or 
Acetic Acid will cause it to disappear. 

b. The Mixed Urates often render a cold 
urine turbid. They subside quite rapidly arid 
form a white or pinkish deposit at the bottom 
and on the sides of the containing vessel, 
much more dense in character than that of the 
phosphates. A gentle heat causes this opacity 
to disappear. 



c. Mucus from the genito-urinary tract may 
occur in sufficient quantity, within the limits of 
health, to cause some opacity in the urine. It 
forms a light, rlocculent sediment, much like 
that produced by the phosphates, but which 
may be distinguished from the latter by the fact 
that alkalies, heat and strong acids have no 
effect upon it, while Acetic Acid increases the 
opacity by coagulating the mucin. 

d. Bacteria. When a specimen of urine is 
allowed to stand for some time, especially in 
hot weather, it becomes opaque on account of 
beginning decomposition and the development 
of Bacteria. This change is important because 
it interferes with the delicacy of the tests for 
Albumen ; and it is on this account that a 
specimen of urine should be examined while 
fresh. 

When, however, it becomes necessary to ex- 
amine for Albumen a specimen of turbid urine, 
which is not rendered transparent by nitration, 
it should be treated by the method suggested by 
Hofman & Ultzman, which is as follows : Add 
to a portion of the urine, in a clean test-tube, 
about one-quarter its volume of Liquor Po- 
tassae, boil the mixture and filter. Should this 



39 



filtrate be not quite clear, add one or two drops 
of Magnesian Fluid,* warm again and filter. 
This filtrate always appears clear and trans- 
parent. The presence of Albumen may then 
be detected by the Nitric Acid test. 

In Disease, the urine may be opaque on 
account of the presence of — 

a. Pus. This forms a deposit which often 
resembles that of the urates. It is distinguished 
from it by the fact that heat increases the opac- 
ity of purulent urine, and from phosphatic de- 
posit by the fact that it is not cleared up by 
the addition of a few drops of acid. 

b. Decomposition, as in old cases of cystitis, 
in which the urine contains bacteria, pus, mucus, 
epithelium and, perhaps, shreds of disorganized 
tissue. 

c. Fat, as in chylous urine. Fat is recog- 
nized by the well-known power of ether to 
dissolve it. 

6a. Albumen. The presence of Albumen in 
the urine is always suggestive of such grave 
pathological conditions that its recognition be- 



*The formula of the Magnesian Fluid is as follows: Magnesium 
Sulphate and Ammonium Chloride, of each one drachm ; Liquor 
Ammoniae, one drachm; Distilled Water, one ounce. Mix. 



4 



comes one of the most important features in 
the examination of urine. Many tests have 
been brought forward for this purpose, and have 
had their earnest advocates, but those which 
have become most generally recognized for 
simplicity and effectiveness are the Nitric Acid 
test and the heat test. 

The Nitric Acid Test. Into a clean test-tube 
about half an inch of pure, colorless Nitric 
Acid is poured. The test-tube being then held 
at a considerable angle, a quantity of clear 
urine is allowed to flow from a pipette slowly 
down the inclined side of the tube, until an 
inch of urine overlies the acid. This must be 
carefully done, so that there shall be no mix- 
ture of the acid and the urine. The presence 
of Albumen is indicated by a sharp, white 
band or zone of coagulated Albumen in the 
urine at the line of contact of the acid with 
the urine. In order to recognize this band, 
where the amount of Albumen is small, the 
tube should be held in a good light against a 
dark background. Sometimes this zone of 
coagulated Albumen develops very slowly, and 
it is, therefore, always well to look at the 
specimen again 15 minutes after the test is 



41 



made, having placed it carefully aside for that 
purpose. 

Errors. A specimen of urine which con- 
tains a large amount of Urates may show a 
whitish zone above the line of contact. This 
is caused by the formation of Acid Urates, 
and is distinguished by the fact that the zone 
is not so sharply denned as that formed by 
Albumen, but fades gradually into the clear 
urine ; also, because it disappears on the ap- 
plication of a gentle heat. 

The presence of resin, not unusual after the 
use of such drugs as Balsam of Copaiba, Tur- 
pentine, etc., produces a whitish zone similar 
to that produced by Albumen. The addition of 
a few drops of Alcohol will redissolve the resin. 

The Heat Test for Albumen. A clean test- 
tube is filled about two-thirds full of urine. 
To the upper part of this urine, heat is ap- 
plied by means of a spirit-lamp. If, when the 
urine has boiled, any diminution of transpar- 
ency is noticed, it is due to Albumen, Mucin 
or the Earthy Phosphates. Then add a few 
drops of Acetic Acid and boil for a few mo- 
ments. If the cloud is due to Phosphates, it 
will disappear ; if caused by Albumen or Mu- 



4^ 



cin, it will persist. Next add carefully to the 
top layer of the urine, one drop of Nitric Acid. 
If the cloud still persists, it is due to Albumen; 
if it disappears, it is caused by Mucin. 

N. B. — The urine must be acid in reaction 
before boiling. If not, add one or two drops 
of Acetic Acid. 

Error. If the urine is slightly turbid from 
decomposition and the presence of Bacteria, 
any delicate change in its opacity cannot be 
seen, and it must be filtered before applying 
the heat. If, after filtration, it still remains 
turbid, it should be treated according to the 
suggestions already made under 5D, Bacte- 
ria. If the specimen is alkaline, Acetic Acid 
should be cautiously used, and if strongly 
acid, Liquor Potassae may be added, so as to 
render the urine only slightly acid. 

If Albumen is not found in a specimen of 
urine subjected to both of these tests, it may 
be safely affirmed that it is not present. 

6b. Sugar. Although many excellent au- 
thorities maintain that the presence of a small 
quantity of sugar in the urine may be entirely 
physiological, yet it is so often the first evi- 
dence of diabetes that its recognition is of the 



43 



utmost importance in examinations for Life 
Insurance. 

Of the various tests which have been de- 
vised for that purpose, the Copper test — as in 
the form of Fehling's Solution* — and the Bis- 
muth test, deserve special mention. The 
composition of Fehling's Solution is based 
upon the fact, not only that sugar has the 
property of reducing the Oxide of Copper to a 
lower state of oxidation, but also that a definite 
quantity of the former will react upon a known 
quantity of the latter (i c. c. of Fehling's So- 
lution is reduced by .005 grams of sugar), and 
it is equally useful for qualitative and quanti- 
tative analysis. 

It is an alkaline fluid, of transparent, deep 
blue color, somewhat easily decomposed by 



* Fehling's Solution is made after the following formula: 34.64 
grams of c. p. Sulphate of Copper are dissolved in 200 grams of dis- 
tilled water; 173 grams c. p. Neutral Tartrate of Soda are dissolved 
in 500 grams of Sodic Hydrate of a sp. gr. 1.12, and to this alkaline 
solution the copper solution is slowly added. The mixture is then 
diluted to one liter. The solution is made and sold by all the large 
drug houses. Perhaps the best preparation is that put up by Dr. E. 
R. Squibb, of Brooklyn, N. Y., and the Medical Examiners of the 
Company are requested, whenever possible, to use this preparation. 

Whenever it is impossible to obtain a reliable preparation of Feh- 
ling's Solution, a fairly good substitute for qualitative work may be 
made as follows: 1 drachm of Sulphate of Copper, 2 drachms of 
Neutral Tartrate of Potash, 3 ounces of Liquor Potassae- Mix. 
Keep this closely corked and in a cool, dark place. It is to be used 
as detailed above for Fehling's Solution. 



exposure to the air and to light and warmth, 
therefore requiring, for its preservation, to be 
kept in small, closely-stoppered bottles, in a 
cool, dark place. 

The Test. A small quantity of the solution 
is poured into a clean test-tube, diluted with 
two or three times its volume of pure water, 
and boiled for a few seconds over a spirit- 
lamp. If the mixture becomes turbid, or a 
yellow or brick-red precipitate forms, it has 
probably been kept too long or has been im- 
properly prepared. If, however, the mixture 
retains its transparent, deep blue color, it may 
be relied upon, and the test is proceeded with. 
To the hot mixture the urine is added, drop 
by drop, and the heat is occasionally applied, 
until a volume of urine has been added equal 
to the volume of the mixture. If sugar is 
present in quantity, the first few drops will 
usually cause a yellow opacity to appear, 
which spreads through the mixture, changing 
slowly to red as it settles to the bottom of 
the test-tube. A small quantity of sugar 
causes this reaction to take place more slowly. 
If no reaction takes place, the urine, clinically 
speaking, is free from sugar. 



45 



Errors, a. The urine must be fresh. A 
small quantity of sugar may fail to cause the 
reaction in an ammoniacal urine. 

b. Albumen interferes with the reaction and 
must be removed before the test is made. 
This may be done by heating the urine, pre- 
viously rendered only faintly acid, and filtering 
it. Care must be taken not to boil the speci- 
men too long. 

c. The changes produced by the earthy 
phosphates must not be confounded with the 
sugar reaction. The former produce a floc- 
culent precipitation in the midst of a trans- 
parent, greenish amber fluid. 

The Bismuth Tests are based upon the fact 
that the action of sugar upon the Bismuth 
salts is the same as upon the Salts of Copper. 
They have advantage over the Copper tests of 
being less sensitive to the decomposing power 
of other organic compounds. 

The Test, which is ordinarily employed 
(Boettger's), is conducted as follows : the 
urine is mixed with an equal volume of Liquor 
Potassae or Sodae, a small quantity of Bismuth 
Subnitrate is added, and the mixture is boiled 
for a short time. If sugar is present, insoluble 



46 



black Oxide of Bismuth is formed and de- 
posited on the sides of the test-tube ; or if the 
quantity of sugar is small, the white Bismuth 
powder becomes tinged with gray. 

Errors. Only a very small quantity of Bis- 
muth should be used, as an excess of Bismuth, 
if the amount of sugar is small, may conceal 
the reaction. 

If Albumen is present in the urine, a re- 
action, due to the formation of the black Sul- 
phide of Bismuth, may take place, which re- 
sembles that produced by sugar and may be 
mistaken for it ; the Albumen should, there- 
fore, be removed from the urine before the 
test is made. 

Another Test for Sugar. Mix equal parts of 
urine and Fehling's Solution in a test-tube and 
let them stand in a moderately cool place for 
twelve hours. If there is any orange-red 
deposit, sugar is present. This test is useful 
mainly as corroborative of others. 

To insure greater certainty in all doubt- 
ful cases, both the Bismuth and Copper tests 
should be employed. 

Microscopical Examination. The value of 
such examination of course depends upon the 



knowledge and skill of the microscopist, and as 
only those thoroughly familiar with such ex- 
aminations will, naturally, be called upon to 
make them, there is no necessity for any in- 
structions as to the paraphernalia or technique 
required. 

IN CONCLUSION. 

We submit these suggestions to the consider- 
ation of the medical gentlemen into whose 
hands as its Medical Examiners and Confi- 
dential Advisers, the Company entrusts grave 
responsibilities, with the hope and belief that 
they will sustain in the future, as they have in 
the past, the honor of their profession, and 
ably protect the interests of the New-York 
Life Insurance Company. 

A. Huntington, M. D., 

Medical Director. 
New York, Oct., 1897. 



